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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421600
Report Date: 01/03/2022
Date Signed: 01/03/2022 02:20:32 PM

Document Has Been Signed on 01/03/2022 02:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:HENRIQUEZ, ROSAFACILITY NUMBER:
013421600
ADMINISTRATOR:HENRIQUEZ, ROSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 244-7813
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 8DATE:
01/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:26 PM
MET WITH:Rosa HenriquezTIME COMPLETED:
02:18 PM
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On 1/3/2022 at 12:26pm Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Rosa Henriquez for an Unannounced Annual Inspection. Present during the inspection was the Licensee, her fingerprint cleated assistant, M. Salgado, two (2) infants, five (5) preschoolers and one (1) school-age child. Licensee’s home was toured for a health and safety inspection. The facility operates 7:30am – 5:30pm, Monday - Friday.

ON LIMITS AREA: Living Room, Dining Area, Kitchen, Family Room, Downstairs Bathroom and Backyard


OFF LIMITS AREA: Entire 2nd Floor and Garage
ISOLATION AREA: Living Room

The facility is a two story home owned by the Licensee. The inside of the home was observed to be neat and clean with ample age appropriate materials for the children. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas.

The home has one (1) fully charged 3A40BC fire extinguisher in the family room. There is one (1) working smoke detector in the family room. There is one carbon monoxide detector at the top of the staircase. The home is equipped with central heat and air for proper ventilation. The fireplace in the family room is blocked by furniture making it inaccessible to the children in care. LPA did not observe any bodies of water in or around the home that could be a potential danger to the children in care. Licensee stated that there is one (1) firearm and one (1) dog in the home. LPA verified that the firearm is properly stored in the home.

Continued on LIC809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: HENRIQUEZ, ROSA
FACILITY NUMBER: 013421600
VISIT DATE: 01/03/2022
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The Licensee’s Health and Safety training has been completed and CPR and First Aid training is complete with an expiration date of 2/23/2023. Licensee's Mandated Reporter training has been completed and expires on 6/23/2023. All required forms are posted and visible for public view by the bathroom door. LPA obtained the children’s files, assistant’s file and the facility roster. All children’s files were missing LIC702 Health History, but otherwise were complete. LPA provided the form for Licensee and instructed her to have each parent fill out the form at pick-up today. LPA obtained the fire/disaster drill log. Log is complete with the last drill logged 10/11/2021.

Licensee was reminded that California Law requires licensees to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com.

Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. The licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

Continued on LIC809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: HENRIQUEZ, ROSA
FACILITY NUMBER: 013421600
VISIT DATE: 01/03/2022
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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Rosa Henriquez.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022
LIC809 (FAS) - (06/04)
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